A Cochrane Review published today finds standardised tobacco packaging may lead to a reduction in smoking prevalence and reduces the appeal of tobacco.

According to the World Health Organisation, tobacco use kills more people worldwide than any other preventable cause of death. Global health experts believe the best way to reduce tobacco use is by stopping people starting to use tobacco and encouraging and helping existing users to stop.

The introduction of standardised (or ‘plain’) packaging was recommended by the World Health Organisation, Framework Convention on Tobacco Control (WHO FCTC) guidelines. This recommendation was based on evidence around tobacco promotion in general and studies which examined the impact of changes in packaging on knowledge, attitudes, beliefs and behaviour. Standardised tobacco packaging places restrictions on the appearance of tobacco packs so that there is a uniform colour (and in some cases shape) with no logos or branding apart from health warnings and other government-mandated information, and the brand name appears in a prescribed uniform font, colour and size.

From next month, UK legislation on standardised packaging for all tobacco packs comes into full effect.

A team of Cochrane researchers from the UK and Canada have summarised results from studies that examine the impact of standardised packaging on tobacco attitudes and behaviour. They have today published their findings in the Cochrane Library.

Tobacco companies want to sell you cigarettes – today, tomorrow and for the foreseeable future. Whether you’re at the tobacco counter or out with friends, glitzy cigarette packaging is a really important part of their sales pitch. Tobacco companies are aware of this. It’s why they are so opposed to their cigarettes being put in plain packaging.

But why would these organisations lobby against plain packaging? On looking into these opposition groups, our recent research gives a clear answer. Opponents of plain packaging tend to have links to the tobacco industry. So much so that three-quarters of organisations identified in our study had financial links to tobacco companies.

Perhaps we shouldn’t be surprised. Decades of research into political activity by the tobacco industry has shown that “third parties” are used to campaign against tobacco-control policies. Health advocates are aware of this. In 2005, the World Health Organisation’s Framework Convention on Tobacco Control committed the countries that signed the convention to protect tobacco policy from interference by the tobacco industry and, crucially, groups linked to them. In response, in 2011, the UK government committed to publishing details of any policy meetings with tobacco companies and the Department of Health routinely requests disclosure of tobacco industry links. So far so good. In doing so, the UK sets a strong example.

Third party interference

But our research shows how “third party” opposition to tobacco control policies extends tobacco industry interference beyond this realm of government. In a three-year period which included the 2012 government consultation on plain packaging, 88% of research and 78% of public communications opposing plain packaging were carried out by organisations with financial links to tobacco companies (see figure 1). And public and retailer campaigns funded by tobacco companies to mobilise opposition to plain packaging generated 98% of the more than 420,000 negative postcard and petition submissions to the consultation.

Figure 1Author provided

In this way, ideas and arguments that come from tobacco companies and their research spill into public spaces. Once there, they can influence the public and political mood on life-saving tobacco control policies and create a misleading impression of diverse and widespread opposition. This is known in the world of political science as “conflict expansion”. And the potential effects are significant. When widespread, these “third party” activities can work to delay and even prevent policies: it took four years to get from consultation to implementation in the UK.

This wouldn’t be so serious if organisations and tobacco companies were open about their relationships. But, in many cases, links were not easy for the research team to detect. Of 150 examples of public communications, less than 20% explicitly acknowledged tobacco industry connections. And, while academics and research consultants tended to clearly report funding sources, “third parties” promoting their research in press releases, news stories and letters to government, frequently did not.

If they were open about their financial relationships with tobacco firms, business and civil society organisations would give the public, politicians and officials the opportunity to scrutinise their arguments and evidence in context. In the case of plain packaging, a lack of openness masked these links and lent credibility to claims that the policy lacked evidence and would increase the trade in illicit cigarettes – claims which have been shown to be unfounded by both peer-reviewed research and by the High Court in Britain. Now, as more countries move to introduce plain packaging, “third party” transparency remains an issue.

In order to help countries guard against tobacco industry interference, awareness can be raised of the effects of their activities on public and political debates. And steps could be taken to make their relationships with tobacco companies clearer. A compulsory register of tobacco companies’ memberships, political activities and associated spending would be a strong first move.

There is strong global commitment to addressing the problem of tobacco industry interference. Parties to the framework convention meet in India in November amid concerns about this issue, and the message to the tobacco industry from the WHO is clear: “The world understands who you are and what you do, and is determined to stamp out the global plague which you do so much to spread.”

About This Project

Packaging is an important marketing tool for tobacco companies, helping to capture attention, create brand awareness, foster positive brand attitudes and communicate product attributes. For smokers, the pack is their personal choice, a statement of their identity, something that stays with them wherever they go and something that it is typically seen countless times a day. The pack turns a generic product into a bespoke marque. Even for non-smokers, tobacco packaging is a familiar feature of life, whether within shops, as litter or in the hands of smoking friends and relatives. It is unsurprising, then, that tobacco companies have been very creative in their use of all elements of the pack – colour, shape and design, the cellophane wrapper, inserts, and the cigarette itself – to communicate the positive qualities of the product and the brand.

Governments have also recognised the importance of packaging as a communications tool. Health warnings, for instance, first appeared on cigarette packs almost half a century ago in the UK, and over time have increased in size and now include pictures. These warnings are a cost-effective and credible means of informing of the health risks of smoking. From May 2017 standardised packaging will be implemented, which will essentially leave all packs looking the same and make the health warnings stand out even more.

Much more could still be done with the packaging however. For instance, pack inserts are an inexpensive means of communication, and have been widely used by tobacco companies. Could the use of inserts, with positively framed messages encouraging smokers to quit and promoting self-efficacy to do so, be of value within the UK? There is also the cigarette itself, which tobacco industry journals refer to as an increasingly important promotional tool. While at a very early stage, academics have begun to explore the possibility of using the appearance of the cigarette to deter smoking, for instance unattractively coloured cigarettes or cigarettes displaying health warnings. Further research exploring these ideas, or the many other potential ways to reduce the appeal of cigarettes, would be of significant value.

There are likely many other possibilities of using the pack to discourage non-smokers from starting and encourage smokers to stop. Supposing, for example, the pack had an audio warning when it was opened? Or it featured a Quick Response barcode on the pack that could direct smartphone users to a stop-smoking service, or similar innovations using barcodes, like augmented reality, which could direct the user to social networking campaigns. The options are many and varied. As the Scottish Government has set a target date for reducing smoking prevalence to less than 5% of the population, and packaging is seen as a crucial platform for health promotion, this PhD could help generate ideas that could help reach this target.

This PhD would have two key objectives:
• To explore the range of possible health promoting packaging innovations, and
• To explore how consumers respond to some of these measures.

Every year in the United Kingdom around 200 000 children start smoking. Half of those who try a cigarette will become regular smokers, putting themselves at risk of tobacco related diseases that can shorten their lifespan by at least a decade. Because of this, the UK and other governments have implemented a range of tobacco control measures over many years, which are intended to both prevent smoking uptake and encourage smoking cessation. Key among these have been measures to restrict the ability of the tobacco industry to market their products to new and existing smokers.

Firstly, traditional forms of advertising such as TV and billboards were banned, followed by sports sponsorship, and, most recently, point of sale displays in shops. All that was left was tobacco packaging: a way to communicate to consumers the appeal of the product and to promote different brands.

My team at the University of Stirling has conducted research on tobacco marketing for many years, funded by Cancer Research UK. Most recently we undertook our own studies on tobacco packaging, and then in 2011 were commissioned by the Department of Health to review all the evidence on plain or “standard packs.” Our review provided the basis for a UK consultation on the issue. At the time we found 37 studies, conducted in different countries and using a variety of research designs. Their findings were consistent. The studies showed that standard packs are: less appealing, increase the visibility and effectiveness of health warnings, and reduce the ability of packaging to mislead people about the harms of smoking.

The first results from Australia – which has introduced plain packaging – show that smokers found plain packaged cigarettes to be “less satisfying and poorer quality” and “were more supportive of plain packaging and more likely to think about and to prioritise quitting”.

Writing in the BMJ, three academics from the University of Stirling – Dr Crawford Moodie, Professor Linda Bauld, and Martine Stead – ask how much more evidence is needed before the UK Government makes a decision on plain-packaged cigarettes.

“Standardised packaging in the UK was first considered as a possible policy measure in the previous Labour government’s consultation on the future of tobacco control in 2008, which cited four studies from North America. By 2011, when the current government launched a consultation on the issue, its evidence review included 37 studies, six of which were from the UK. Since that review at least 12 additional studies have been published, including three more from the UK.

“This growing body of research is consistent in its findings: that plain packaging would reduce the appeal of tobacco products to consumers; would increase the effectiveness of health warnings; and would reduce the ability of packaging to mislead consumers about the harmful effects of smoking.” Continue reading →

Today the laws around tobacco packaging have changed! Under new regulations voted for by MPs, tobacco and cigarettes can only be sold in plain, standardised packaging.

The decision to make these changes as a public health measure to protect children’s health was informed by the work of many researchers across the tobacco field. The UK Centre for Tobacco and Alcohol Studies, its stakeholders and our researchers welcome this move to protect the UK population from being advertised to by tobacco branding and attractive images.

A systematic review of evidence of standardised packaging carried out by the Institute of Social Marketing at the University of Stirling showed that standard packs are less appealing, make health warnings more effective, and reduce the ability of the packaging to mislead consumers about the harms of smoking.

Under the new regulations, all tobacco products will be sold in dark green packages, with brand features and bright colours replaced with large graphic images of the effects of smoking and health warnings.

Gerard Hastings, Professor of Social Marketing said: “The introduction of plain packaging is another giant step forward in the fight against tobacco, which is still killing tens of thousands of people every year in Britain. Over the last two decades we have blocked the tobacco industry’s pernicious marketing in the media, in our shops and now on the pack itself. The big winners will be our children, who will escape being groomed for addiction and early death in the interests of private profit. Today is a day which every parent, every teacher and every child can cheer to the roof tops.”

Martine Stead, Deputy Director of the Institute for Social Marketing said: “We have examined evidence of the potential impact of standardised packaging from Australia, New Zealand, the UK, Canada and France. The evidence is clear: putting cigarettes into plain packs makes tobacco products, and smoking in general, less appealing to young people. People pay more attention to health warnings when packs have no distracting branding on them. The colour is also important as people assume white packs are somehow less harmful than darker coloured packs. This confusion disappears when all packs are the same dark colour.”

Crawford Moodie, Senior Research Fellow, said: “Australia remains the only country to have fully implemented plain packaging. Large national surveys with both adults and youth there show since the regulation was introduced, prevalence and consumption has declined, with fewer adults and young people smoking now than at any time since these surveys began. ,There’s also been an increase in the average age of smoking initiation and the proportion of never smoking. The evidence in favour of plain packaging is now stronger than it has ever been.”

Dr Jenny Hatchard, Research Fellow at the University of Bath said “Our research showed that tobacco company claims that plain packaging “wouldn’t work”, would increase the illicit trade in tobacco and would damage the economy were largely unfounded and based on low quality research. Yesterday’s High Court decision is an important moment for plain packaging and the positive impacts it will have on health. However, it also sends an important message that public health legislation cannot and should not be undermined by the poor quality evidence and opposition tactics of powerful corporations whose products damage our health.”

Also happening today are changes to the current rules around tobacco related products including e-cigarettes. This includes restrictions around advertising and promotion of e-cigarettes and how products containing different levels of nicotine are regulated.

Commenting on the developments to e-cigarette regulations, Linda Bauld, Professor of Health Policy, said: “Electronic cigarettes are now used by 2.8 million adults in the UK, with almost half of these users being ex-smokers. All existing research suggests that while e-cigarettes shouldn’t be promoted to children who have never smoked, they offer a far safer alternative for people who currently use tobacco.

New EU regulations on e-cigarettes are contained in one specific part of the TPD – Article 20 – which imposes new restrictions on these devices. TPD limits on nicotine concentration, tank size and e-liquid containers are not well supported by existing evidence. Only time will tell if Article 20 has unintended consequences, and this needs to be the focus of future careful research and monitoring.”

Side note: The evidence that e-cigarettes can help and have helped people stop smoking is growing and some people are worried that Article 20 of the TPD will affect the success of these products and have a substantial impact on the almost 3 million current vapers currently in the UK. This lead the House of Lords to table Article 20 of the TPD until June 20th at which time representatives will vote whether or not to implement that part of the legislation. With the EU referendum due soon after, the result of the vote will have huge ramifications on voters’ decision to vote to stay/leave the EU, a debate that is increasingly becoming polarised from both sides of the argument. Read more here.

Implementation of plain packaging for cigarettes and loose tobacco will go ahead on schedule today (Friday, 20 May 2016) after yesterday’s ruling from the UK High Court, which found in favour of the Department of Health.

The ruling relied partly on two key pieces of peer-reviewed research from the Tobacco Control Research Group at the University of Bath to conclude that evidence submitted by the tobacco industry to the public consultation on plain packaging ‘generally fell below best practice’ as it was not peer-reviewed, benchmarked against internal documents, did not make use of global literature and was not verifiable.

The research papers, published in BMJ Open and PLOS Medicine in 2014, had found that tobacco industry evidence:

Was of significantly lower quality than research supporting the measure.

Used techniques, such as misquoting, to encourage government and the public to question the quality of the evidence supporting standardised packaging;

Failed to include evidence showing the central importance of packaging in marketing their products; evidence which is present in internal tobacco company documents made public via litigation; and

Did not consistently and transparently disclose their links to the evidence they cited.

Lead author of one of the papers, Dr Jenny Hatchard, said ‘Our research showed that tobacco company claims that plain packaging “wouldn’t work”, would increase the illicit trade in tobacco and would damage the economy were largely unfounded and based on low quality research.

‘Yesterday’s High Court decision is an important moment for plain packaging and the positive impacts it will have on health. However, it also sends an important message that public health legislation cannot and should not be undermined by the poor quality evidence and opposition tactics of powerful corporations whose products damage our health.’